Billing and Documenting Procedures Out of the Operating Room

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by Ed Mariano, MD, MAS:

Congratulations on finishing residency! Now that you have learned all there is to learn about anesthesiology as written in the textbooks, it’s time to learn (quickly) all the practical aspects of earning a living as an anesthesiologist.

When you join a new practice or department, more than likely you will have access to personnel charged with billing and coding for your work. Anesthesiology is a unique medical specialty in that the majority of our work (providing anesthesia) is charged according to time “units” (1 unit=15 min of anesthesia time) with additional start-up units based on multiple factors. Coding and billing such work is relatively straightforward with handy reference like the American Society of Anesthesiologists (ASA) Relative Value Guide.

Therefore, I want to focus this article on documenting and billing for anesthesiologists’ procedures out of the operating room (OR). I will cover evaluation and management encounters in a separate article. Timed anesthesia services out of the OR are typically charged the same way as anesthesia provision in the OR, but procedural services are different. While anesthesia billing services are very familiar with looking up Current Procedural Terminology (CPT) codes, we should not expect them to be able to interpret our handwritten procedure notes and deduce the appropriate code every time. To prevent confusion, I suggest creating standardized procedure notes and including CPT codes. This also applies to electronic health record by creating standardized templates. Perhaps you may think it’s “below you” to do your own coding, or maybe you just feel uncomfortable with it, but I’ll tell you that it makes a difference in what your billing service charges on your behalf and what you and your group eventually get paid.

Referring Provider. When anesthesiologists perform procedures out of the OR, we function as a consultant. Consultants receive referrals, and the referring physician or provider and reason for referral should be listed on your procedural documentation.

Procedural Coding. Since my area of expertise is in regional anesthesiology and acute pain medicine, I will use examples from this area. However, the lessons apply to other aspects of out-of-OR anesthesia as well. When coding for a procedure (e.g., nerve block, vascular access procedure, or emergency intubation), it helps to have a reference list of CPT codes from which to choose. If not available, you can check online resources or available coding apps. Procedures, even for anesthesiologists, have an established amount of “work” assigned (i.e., relative value units or RVUs) regardless of the time it takes to perform them that is used to determine charge. This differs from anesthesia billing and identical to surgery billing.

Diagnosis Coding. When performing and documenting a procedure, there needs to be an associated diagnosis that can be found among the International Classification of Diseases (ICD)-9. For example, after performing emergency endotracheal intubation (CPT: 31500), you should include a diagnosis such as acute respiratory failure (ICD-9: 518.81). In regional anesthesiology, nerve block procedures are often performed for postoperative pain management. When documenting these procedures, the appropriate CPT code is selected based on the block performed and a corresponding diagnosis code is included. For example, you may document and code for a femoral nerve block catheter (CPT: 64448) that you inserted for a patient with knee pain (ICD-9: 719.46).

Modifiers. Specific modifiers are used with certain CPT codes to provide additional information in the claim and increase the likelihood of correct payment. For example, including the modifier -59 (distinct procedure) for a nerve block performed for postoperative pain distinguishes the block from the intraoperative anesthetic technique. Other pertinent modifiers in regional anesthesiology include -50 (bilateral), -51 (multiple procedures), and -26 (professional component) when using ultrasound guidance (CPT: 76942).

CPT codes are updated every year, so it is important to stay on top of proposed changes. Category III codes emerge from time to time (ending in “T” such as 0213T for ultrasound-guided paravertebral injection) and are considered temporary codes to assess expected volume for new procedures or services. I strongly recommend consulting with your practice or departmental leadership and billing company to ensure compliance with billing regulations in your area. Finally, actual payment rates will vary between practices due to differences in payer mix and locality.

For more information about adding value and billing for regional anesthesiology and acute pain medicine services, please visit my website.

Recommended Reading:

  1. Mariano ER: Making it work: setting up a regional anesthesia program that provides value. Anesthesiol Clin 2008; 26: 681-92, vi
  2. Gerancher JC, Viscusi ER, Liguori GA, McCartney CJ, Williams BA, Ilfeld BM, Grant SA, Hebl JR, Hadzic A: Development of a standardized peripheral nerve block procedure note form. Reg Anesth Pain Med 2005; 30: 67-71
  3. Greger J, Williams BA: Billing for outpatient regional anesthesia services in the United States. Int Anesthesiol Clin 2005; 43: 33-41    
  4. Kim TW, Mariano ER: Updated guide to billing for regional anesthesia (United States). Int Anesthesiol Clin 2011; 49: 84-93
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